Covers the four courses of MS: relapsing-remitting, secondary progressive, primary progressive, and progressive relapse. Discusses early and advanced symptoms. Also covers complications. Discusses diagnosis and treatment. Includes info on pregnancy and MS.

Multiple Sclerosis (MS)

Topic Overview

What is multiple sclerosis?

Multiple sclerosis,
often called MS, is a disease that affects the
central nervous system—the brain and spinal cord. It
can cause problems with muscle control and strength, vision, balance, feeling,
and thinking.

Your nerve cells have a protective covering called
myelin. Without myelin, the brain and spinal cord can't communicate with the
nerves in the rest of the body. MS gradually destroys myelin in patches
throughout the brain and spinal cord, causing muscle weakness and other
symptoms. These patches of damage are called lesions.

MS is
different for each person. You may go through life with only minor problems. Or
you may become seriously disabled. Most people are somewhere in between.
Generally, MS follows one of four courses:

What causes MS?

The exact cause is unknown, but
most experts believe that MS is an autoimmune disease. In this kind of disease, the
body's defenses, called the
immune system, mistakenly attack normal tissues. In
MS, the immune system attacks the central nervous system—the
brain and spinal cord.

Experts don't know why MS happens to some
people but not others. There may be a
genetic link, because the disease seems to run in
families. Where you grew up may also play a role. MS is more common in those
who grew up in colder regions that are farther away from the equator.

What are the symptoms?

Symptoms depend on which
parts of the brain and spinal cord are damaged and how bad the damage is. Early
symptoms may include:

Muscle problems. You may feel weak and stiff,
and your limbs may feel heavy. You may drag your leg when you walk.

Vision
problems. Your vision may be blurred or hazy. You may have eyeball pain
(especially when you move your eyes), blindness, or double vision.

Sensory problems. You may feel tingling, a
pins-and-needles sensation, or numbness. You may feel a band of tightness
around your trunk or limbs.

Balance problems. You may feel lightheaded or dizzy or
feel like you're spinning.

How is MS diagnosed?

Diagnosing MS isn't always
easy. The first symptoms may be vague. And many of the symptoms can be caused
by problems other than MS.

MS is not
diagnosed unless a doctor can be sure that you have had at least two attacks affecting at least two different areas of your central nervous system.
The doctor will examine you, ask you questions about your symptoms, and do some
tests. An
MRI is often used to confirm the diagnosis, because
the patches of damage (lesions) caused by MS attacks can be seen with this
test.

How is it treated?

Medicines are used to treat MS:

During a relapse, to make the attack shorter
and less severe.

Over a long period of time, to keep down the
number of attacks and how severe they are and to slow the progression of the disease. (This is called disease-modifying therapy.)

To control specific symptoms.

You may find it hard to decide when to start taking the drugs that slow the progression of MS. The drugs may not work for everyone, and they often have side
effects. You and your doctor will decide together when you should start any of these
drugs.

How do you live with MS?

There is no cure for MS. Treatment and self-care can
help you maintain your quality of life.

Physical therapy, occupational therapy, and
speech therapy can help you manage some physical problems caused by MS. You can
also help yourself at home by eating balanced meals, getting regular exercise and rest,
and learning to use your energy wisely.

Dealing with the physical
and emotional demands of MS isn't easy. If you feel overwhelmed, talk to your
doctor. You may be depressed, which can be treated. And finding a support group
where you can talk to other people who have MS can be very helpful.

Cause

The cause of multiple sclerosis (MS) is unknown. Because a person's
risk of MS is slightly higher in some families when a relative has MS, there may be a
genetic link. For more information, see What Increases Your Risk.

Symptoms

The symptoms of
multiple sclerosis (MS) vary from person to person
depending on which parts of the brain or spinal cord (central nervous system) are damaged. The
loss of myelin and scarring caused by MS can affect
any part of the central nervous system. Myelin is the insulating coating around a nerve.

Symptoms may come and go or become more or less severe from day to day or, in rare cases, from hour to hour.
Symptoms may become worse with increased body temperature or after a
viral infection.

Early symptoms

Common early symptoms of MS
include:

Muscle or motor symptoms, such as weakness, leg dragging, stiffness, a tendency to drop
things, a feeling of heaviness, clumsiness, or a lack of coordination (ataxia).

Visual symptoms, such as blurred, foggy, or hazy vision, eyeball pain
(especially when you move your eyes), blindness, or double vision. Optic
neuritis—sudden loss of vision that is often painful—is a fairly common first
symptom. It occurs in up to 25 out of 100 people who have MS.

Sensory symptoms, such as tingling, a
pins-and-needles sensation, numbness, a band of tightness around the trunk or
legs, or electrical sensations moving down the back and legs.

Advanced symptoms

As MS progresses, symptoms may
become more severe and may include:

Worse muscle problems, and stiff,
mechanical movements (spasticity) or
uncontrollable shaking (tremor). These problems may make walking
difficult. A wheelchair may be needed some or all of the time.

Pain
and other sensory symptoms.

Bladder symptoms, such as an inability to hold urine (urinary incontinence) or to completely empty the bladder, or a loss of bladder sensation.

Feeling very tired (fatigue). This can be worse if symptoms
such as pain, spasticity, bladder problems, anxiety, or depression make it
hard to sleep.

What Happens

In general,
multiple sclerosis follows one of four courses:

Relapsing-remitting, where symptoms may
fade and then recur at random for many years. The disease doesn't advance
during the remissions. Most people who develop MS have a
relapsing-remitting course. In 8 to 9 out of 10 people with this course of MS, the relapsing-remitting phase lasts about 20 years.1

Secondary progressive, which at first follows a relapsing-remitting course. Later
on, it becomes steadily progressive.

Progressive relapsing, where steady
deterioration of nerve function begins when symptoms first appear. Symptoms
appear and disappear, but nerve damage continues. Few people have this course
of MS.

MS is different for every person. You may go through life with only minor problems. Or you may become seriously disabled. Most people are somewhere in between.

The duration of the disease varies. Most people who get MS
live with it for decades.

Progress of MS

MS usually progresses with a series of
relapses that occur over many years
(relapsing-remitting MS). In many people the first MS attack involves just a
single symptom. It may be weeks, months, or years before you have a relapse.

As
time goes by, symptoms may linger after each relapse so you lose the ability to
fully recover from the relapse. New symptoms often develop as the disease
damages other areas of the
brain or spinal cord.

Some people have a few
mild attacks from which they recover entirely. This is called benign MS.

Although rare, a small number of people die within several years of the
onset of MS. This is called malignant or fulminant MS.

Because MS may affect your ability to move and walk, it
can place limits on your daily living, particularly as you age. If you or someone in
your family has MS, talk to your doctor about
how MS may affect daily living. Knowing what to expect will help you plan
for the future.

Complications of MS

Reduced ability to move and
walk. This makes it necessary to use a wheelchair some or all of the
time.

What Increases Your Risk

Your risk for
multiple sclerosis (MS) increases with:

Geographic location, or where you lived
during childhood (up to age 15). People who spend the first 15 years of their
lives in colder climates that are farther away from the equator tend to be more
likely to get MS than people who lived closer to the equator during those
years.

Family history of MS. About 15 out of
100 people who have MS have a relative with MS, most often a brother or sister.2

Certain genetic
characteristics associated with the
immune system. These appear more frequently in people who
have MS. This may mean that there are one or more
genes that may increase the chance of getting
MS.

Race. People of Western European
ancestry are more likely to get MS.

Being female. MS is about 3
times as common in women as in men.

When To Call a Doctor

Some of the symptoms of
multiple sclerosis (MS) are similar to those of many
other illnesses. See your doctor if over a period of time you have more than
one symptom, such as:

Tingling or a pins-and-needles sensation; numbness;
tightness in a band around the trunk, arms, or legs; or electric shock
sensations moving down the back, arms, or legs.

Inability to hold
urine or to completely empty the bladder.

Dizziness and
unsteadiness.

Problems with memory, attention span, finding the
right words for what you mean, and daily problem-solving.

If you have been diagnosed with MS, see your doctor
if:

Your attacks become more frequent or
severe.

You begin having a symptom that you have not had before or
you notice a significant change in symptoms that are already present.

Watchful waiting

Milder MS-type symptoms can be caused by many
other conditions or may occur now and then in healthy people. For example, lots of
people have minor numbness in their fingers or a mild dizzy spell once in
a while. Stiffness and muscle weakness can result from being more active than
usual.
A wait-and-see approach (watchful waiting) is appropriate for these types of
everyday aches and pains, so long as they do not continue.

If your
symptoms occur more often or don't go away, talk to your doctor.

For people with MS

Talk to your doctor about
what to expect from the disease and from treatment. MS is an unpredictable
disease, but you probably can get some idea of what is "normal" and what
symptoms or problems are reasons for concern.

Some people who have MS
want active, regular support from their doctors. Others want to manage their
condition on their own as much as possible. Wherever you are in this range,
find out which signs or symptoms mean that you need to see your doctor. And
seek help when you need it.

Who to see

Health professionals who may be involved in evaluating
symptoms of MS and treating the condition include:

Family doctors or
internists. Consult your doctor when symptoms first
start. He or she will refer you to a neurologist if needed. If you have
MS, your family doctor or internist can treat your general health problems even
if you see a neurologist for MS treatment.

Neurologists. A
neurologist can decide whether your symptoms are caused by MS. He or she can also help you
decide what may be the best treatment for your condition.

Many university medical centers and large hospitals have
MS clinics or centers staffed by neurologists and other health professionals
who specialize in diagnosing and treating MS. They may be able to provide the
most thorough evaluation.

If you have been diagnosed with MS, at
some point you may need to seek the help of:

A
physical therapist, to assist with exercise to
maintain body strength and flexibility and deal with movement
problems.

An
occupational therapist, to identify ways of
accomplishing daily activities if MS has caused any physical
limitations.

A
pain management specialist, to help with any
significant chronic pain that MS may cause. A pain specialist,
often as part of a pain clinic, can help find ways of reducing pain when
possible and dealing with pain that doesn't go away.

Exams and Tests

Diagnosing
multiple sclerosis (MS) isn't always easy and in some cases may take time.

Your medical history and
neurological exam can identify possible nervous
system problems and are often enough to strongly suggest a diagnosis of MS.
Tests may help confirm or rule out the diagnosis when your history and
exam do not provide clear evidence of the disease. MRI and neurological exam may help doctors predict which people
will develop MS after a first attack of symptoms.

Confirming the diagnosis

MS is diagnosed when it is clear from neurological tests and a neurological exam that lesions
(damaged areas) are present in more than one area of the central nervous system (usually the brain, spinal cord, or the nerves to the
eyes). Tests will also clearly show that damage has occurred at more than one point in time.

Some people have had only one episode of a neurological symptom such as optic
neuritis, but MRI tests suggest they may have MS. This is known as a clinically
isolated syndrome. Many of these people go on to develop MS over time.

Tests to diagnose other health problems

Urinary tract tests may be needed to help diagnose a
problem with bladder control in a person who has MS.

Neuropsychological tests may be needed to identify
thinking or emotional problems, which may be present without the person being
aware of them. Typically, these tests are in a question-and-answer
format.

A blood test for JC virus antibodies may be done. This test can help you and your doctor understand your risk for getting a rare but serious brain infection called PML (progressive multifocal leukoencephalopathy).

Treatment Overview

Treatment can make living with
multiple sclerosis (MS) easier. Your type of treatment
will depend on how severe your symptoms are and whether your disease is active
or in remission. You may get medicines, physical therapy, and other treatment at home.

Medicines

Medicines are used to treat relapses, control the course of the disease (disease-modifying drugs or DMDs), or treat symptoms.

The National Multiple
Sclerosis Society recommends that people with a definite diagnosis of MS and
who have active, relapsing disease start treatment with medicines. This group also recommends treatment with medicine after the first attack in some people who are at a high risk for MS.3

If you decide
not to try medicines at this time, meet with your doctor regularly to check whether the disease is progressing.

Ongoing monitoring

You and your doctor will set up a schedule
of periodic appointments to monitor and treat your symptoms and follow the
progress of your MS. Monitoring your condition helps your doctor find out
if you may need to try a different treatment.

Home treatment

End-of-life issues

In rare cases,
MS is life-threatening. If your
condition gets considerably worse, you may want to make a living will,
which allows your wishes to be carried out if you are not able to make
decisions for yourself. For more information, see the topic
Care at the End of Life.

Prevention

In general, there is no way to prevent
multiple sclerosis (MS) or its attacks. For people
with
relapsing-remitting MS and secondary progressive MS, treatment with medicine may reduce the frequency of relapses and delay disability.

Home Treatment

If you have
multiple sclerosis (MS), it is important to find ways
of coping with the practical and emotional demands of the disease. These are
different for everyone, so home treatment varies from person to person.

Home treatment may involve making it easier to get around your home,
dealing with
depression, handling specific symptoms, and getting
support from your family and friends.

Modify your home to keep it safe and easy to get around. For example, to help prevent falls, install grab bars in the bathroom and don't use throw rugs. And try adjusting your daily schedule so that
your routine is less stressful or tiring.

Be active, either on your
own or with the help of a physical therapist.

Avoid getting overheated. Increased body temperature can
temporarily make your symptoms worse. Use an air conditioner, keep your home
somewhat cool, and avoid hot swimming pools and hot tubs. During warm or hot
weather, exercise in an air-conditioned area rather than outdoors.

Eat plenty of fruits, vegetables,
grains, cereals, legumes, poultry, fish, lean meats, and low-fat dairy
products. A balanced diet for a person who has MS is the same as that
recommended for most healthy adults.

Disease-modifying treatment

Strong evidence suggests that MS is caused by the
immune system causing
inflammation and attacking nerve cells and myelin, which is the protective coating
surrounding the nerve fibers. Medicines that change the way the immune system works can reduce the number and severity of attacks that damage the nerves and myelin.

For people who have
relapsing-remitting MS, disease-modifying therapy can reduce
the number and severity of relapses. It may also delay disability in some people. Some of these medicines may also delay
disease progression and reduce relapses in some people who have
secondary progressive MS.

Some people have
only one episode of a neurological symptom such as
optic neuritis. Yet
MRI or other tests suggest that these people have MS. This is known
as a clinically isolated syndrome. Many of these people go on to develop MS
over time. In most cases, doctors will prescribe medicine for people who have had a clinically isolated syndrome.
These medicines, when taken early or even before you have been diagnosed with
MS, may keep the disease from getting worse or extend your time without
disease.3

Relieving symptoms

Treating specific symptoms can
be effective, even if it doesn't stop the progression of the disease. Symptoms
that can often be controlled or relieved with medicine include:

Medicines can also help with sexual problems, emotional problems, and walking problems. Sildenafil (Viagra) can help with sexual problems in both men and women. Clomipramine may also
be given to improve
erectile dysfunction. Dextromethorphan and quinidine (Nuedexta) is a medicine that can be used for uncontrollable outbursts of crying or laughing at strange or inappropriate times. Dalfampridine (Ampyra) is a medicine that can be used to help with walking problems.

Medicine may be used only some of the time or regularly, depending
on how severe or constant a certain symptom is. Changes in diet, schedule,
exercise, and other habits can also help manage some of these symptoms. See Home Treatment.

Cannabinoids are substances found in marijuana. Similar drugs can be created in a lab. Some forms of natural and man-made cannabinoids may help with symptoms such as pain and spasticity. They are not available in all areas. Talk to your doctor if you are considering cannabinoids.

Medicines being studied

A variety of
other medicines and biological chemicals have been tried or are being studied as
therapy for MS. None of them have been clearly proved as beneficial, and none have
been approved for treatment of MS.

Several medicines are being tested in
clinical trials. People with MS who have not responded
to standard therapy sometimes choose to take part in these trials. To learn
more about clinical trials, talk to your doctor or contact the National
Multiple Sclerosis Society at www.nationalmssociety.org.

Deciding about disease-modifying therapy

The National Multiple Sclerosis Society recommends that people with a definite diagnosis of MS and active, relapsing
disease start treatment with interferon beta or glatiramer. Most neurologists support this recommendation and now
agree that permanent damage to the nervous system may occur early on, even while symptoms are still quite mild.
Early treatment may help prevent or delay some of this damage. In general, treatment is recommended until it no
longer provides a clear benefit.

The National MS Society also says that treatment with medicine may be considered after the first attack in some
people who are at a high risk for MS (before MS is definitely diagnosed).

Despite the recommendation, some people find it hard to decide whether to begin disease-modifying therapy,
especially when their symptoms have been fairly mild. Some may not want to bear the risks and side effects of
medicine when they are not sure they need it. Some may want to see whether their disease gets worse before they
start therapy. A small percentage of people diagnosed with MS may never have more than a few mild episodes and
may never develop any disability, but the disease is unpredictable.

Treating symptoms and relapses

The need and desire for medicine vary. If your symptoms are mild, you may choose to manage
them without any medicine. If you have specific symptoms that are causing
problems, certain medicines may help you keep them under control. Or you may
want to use medicine only during a relapse.

You may also want to
think about:

The possible side effects of using steroids
or other medicines to treat symptoms or control a relapse. Some people have
only minor side effects. But others may have side effects that concern them
more than their MS symptoms.

The costs of treating symptoms and
controlling relapses. In some cases, using medicine to control symptoms and
relapses may reduce the need for hospital stays.

Other personal
issues that you face at work or at home.

Also keep in mind that it can be hard to tell if
medicine is helping. Multiple sclerosis is a disease with spontaneous
remissions. This means that your condition can improve on its own, without any
treatment. Just because your symptoms improve after treatment doesn't mean
that a treatment is working.

Surgery

People with
multiple sclerosis (MS) who have severe
tremor (shakiness) affecting movement may be helped by
surgery. People with severe
spasticity (muscle stiffness) may be helped by
insertion of a spinal pump to deliver medicines when oral medicines
fail.

Surgery choices

Surgery options include:

Deep brain stimulation for tremor.
This treatment is only considered after other options have failed. Severe and disabling tremor that occurs with the slightest movement of the
limbs may be helped by an implanted device that stimulates an area of the
brain. A
neurological surgeon does the surgery to implant
the device.

Implantation of a drug catheter or pump, for
spasticity. This treatment is only considered after other options have failed. People who have severe pain or spasticity may benefit from having a
catheter or pump placed in the lower spinal area to deliver a constant flow of
medicine, such as baclofen.

Other Treatment

The unpredictability and
variety of symptoms caused by
multiple sclerosis (MS) make it a disease that people
have tried to treat in many different ways.

Complementary therapies

Many complementary therapies have been proposed as
treatments for MS. None of these treatments have been shown to modify the
course of the disease. Some of those most commonly used are:

Although clinical research has not shown all of these
complementary therapies to be effective, a person with MS may benefit from safe
nontraditional therapies along with conventional medical treatment. Some
complementary therapies may help relieve
stress, depression, fatigue, and muscle tension. And some may improve your overall
well-being and quality of life. Talk to your doctor if you are
interested in trying any of these complementary therapies or alternative medical approaches to MS treatment.

Clinical research also has been
unable to show that treatments such as "liberation" angioplasty for chronic cerebrospinal venous insufficiency (CCSVI), bee venom therapy, Prokarin (a caffeine
and histamine combination),
removal of mercury fillings (dental amalgams), and
hyperbaric oxygen therapy have any benefits for people
who have MS. Some of these therapies may be harmful as well as expensive and are not recommended by most experts.

Experimental medical treatments

Experimental
treatments for MS involve reducing the activity of the
immune system. This may be done with
medicines and biological chemicals or through methods such as
total lymphoid irradiation, in which the entire lymph
node system is exposed to radiation. While these methods have been used with success in
the treatment of certain other medical conditions, they have failed to produce
significant benefits when tested in controlled clinical trials. They remain
experimental treatments for MS.

Stem cell transplant, which uses immature cells from the bone marrow, has been studied. Early results suggest that stem cell transplant may delay disability, especially in people with relapsing-remitting MS.4 Stem cell transplant may be an option for people who have very aggressive or malignant forms of MS.5 It remains unproved and isn't recommended for treating relapsing-remitting MS.

What to think about

There is no cure for MS. So far, the only treatments proved
to affect the course of the disease are approved disease-modifying therapies. Other types of treatment should not replace these medicines if you are a candidate for
treatment with them.

Some people who have MS report that complementary therapies have worked for them. This may be in part due to the
placebo effect. The placebo effect means that you feel better after getting treatment, even though the treatment has not been proved to work. And even if some complementary
therapies don't treat the disease itself, they may affect a person's sense of well-being and help the person feel better and healthier.

If you are
thinking about trying a complementary treatment, get the facts first. Discuss these questions with your doctor:

Is it safe? Talk with
your doctor about the safety and potential side effects of the treatment. This
is especially important if you are on drug therapy for MS. Some
complementary treatments in combination with drug therapy can be quite
dangerous. A treatment that could be harmful to you and may or may not improve
your symptoms isn't worth the risk.

Does it work? Because MS symptoms can come and go, you may find it hard to
judge whether a particular treatment is really working. Keep in mind that if
you get better after using a certain treatment, the treatment isn't always the
reason for the improvement. MS may often improve on its own (spontaneous
remission).

How much does it cost? An
expensive, unproven treatment that may or may not help you may not be worth its
cost. Beware of therapy providers or products that require a large financial
investment at the beginning of a series of treatments.

Will it improve my general health? Even if they aren't
effective in treating MS, some complementary practices (such as acupuncture,
massage, or yoga) may be safe. And they may lead to healthy habits that improve your
overall well-being. These might be worth trying.

With a hard-to-treat disease like MS, it can be tempting
to jump at the promise of an effective treatment. Be cautious about trying
unproven treatments.

Marriott JJ, et al. (2010). Evidence report: The efficacy and safety of mitoxantrone (Novantrone) in the treatment of multiple sclerosis: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology, 74(18): 1463–1470.

Vijayshree Y, et al. (2014). Summary of evidence-based guideline: Complementary and alternative medicine in multiple sclerosis: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology, 82(12): 1083–1092.

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